Skin Deep - Clinical & Cosmetic Dermatology Blog

Skin Deep is a blog for dermatologists and skin care professionals with focus on theoretical, cosmetic and aesthetic dermatology. This blog is associated with ‘Dermatologists Sans Borders’ one of the largest curated groups of skin care professionals on facebook. If you are looking for non-technical information, please visit

Cosmetic Dermatology Industry: (Risk of) New entrants (Part 2)

Greater Middle East
Greater Middle East (Photo credit: Wikipedia)
The threat of new entrants in Cosmetic Dermatology depends on 2 main factors. The licensing process and the initial investment. The licensing process for dermatologists has never been an issue in India. But It was a huge barrier in most parts of Middle East. However the regulatory bottle necks are changing fast. The recent socio-political changes in the Middle East may also have a significant effect on this.  We can expect an increase in the number of practicing dermatologists in the Middle East in the short to medium term.

There has been no disruptive innovation in the cosmetic devices industry comparable to Botulinum toxin and dermal fillers. The competition is increasing in the device manufacturing arena as well though it has not impacted the revenue stream of the manufacturers, because of the disproportionate increase in the number of dermatologists. Manufacturers have tried to compensate for the lack of innovation by introducing new models with minimal clinical impact. This has lead to the flooding of the market with old models that are not much different from the new models. The distributes have started offering this models on a rental basis. This has significantly reduced the initial investment involved.

New entrants will lower the costs, at the same time add ease and convenience, without much impact on the quality. Consumers will, of course, welcome this though there may be a lag period before they realize that the quality is more or less same. Lower costs obviously means lower profits. The oldies who have branched out are more vulnerable to the blow to their bottom line.

Cosmetic dermatology in these regions is experiencing the same shift seen in banking, retail and entertainment as new entrants whose core business resides outside of dermatology and even healthcare are emerging to capture more of the market. The dermatologist CEOs could look at some of these newbie with a wealth of experience in other sectors. If they are making some headway, don’t hesitate to look for opportunities to partner.

In the next post on this series, I will discuss the threat of substitute products or services. Hate to steal my own thunder, but would your patients prefer to send a digital photo of a rash or skin condition for you to diagnose?

This is a series with six parts. Read the full series here

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Best anti-ageing nanoparticle: Clean air

Nanoparticle Catalyst Electrode
Nanoparticle Catalyst Electrode (Photo credit: Argonne National Laboratory)
I still remember seeing a device displaying a controlled explosion inside a chamber magically producing nanoparticles from any cream or lotion that you introduce into the chamber. It was a “back to the future” moment for me! The demonstrator (with a remarkable resemblance to Einstein) almost claimed that he has a technology for controlled atomic fission. Now I even believe cosmetic dermatology is the answer to the world’s energy crisis!

On a serious note, In this short but information rich article titled  “Aging in a polluted world”, [1] Dr Zoe Diana Draelos, the editor of journal of cosmetic dermatology proposes her views on the menace of pollution. She warns about the potential problems of the “real nanoparticle”. Many of the “ageing gracefully” proponents may not quite like her closing remarks:

 “No diet or cosmetic cream can quench the reactive oxygen species created by nanoparticle pollution. Perhaps the answer to aging gracefully is too simple. Life in a healthy rural environment with clean air may be the solution to longevity.

She also refers to articles by Vierkotter and Krutmann about the link between polycyclic aryl hydrocarbons from soot nanoparticles causing forehead and cheek pigmentation. Do you believe this could be an etiological factor for the elusive south asian pattern of forehead pigmentation?

BTW Does anyone among us actually look like Einstein :)  ? 

Albert Einstein during a lecture in Vienna in 1921
Albert Einstein during a lecture in Vienna in 1921 (Photo credit: Wikipedia)
1. Draelos, Zoe Diana. "Aging in a polluted world." Journal of cosmetic dermatology 13.2 (2014): 85-85.

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Seeing things in a new light: Sensors that could change dermatology

A remote control's infrared seen as near-infra...
A remote control's infrared seen as near-infrared through a still image from the camera's CCD sensor. (Photo credit: Wikipedia)
When researcher Dr Richard Curry from the University of Surrey’s Advanced Technology Institute, published his new light sensor in Nature’s Scientific Reports, there was no mention of its potential use in dermatology. Researchers believe that having a single low cost near infrared system, in addition to conventional imaging, opens up many new possibilities. [1]

“The new technology could allow surgeons to ‘see’ inside tissue to find tumours prior to surgery as well as equip consumer products, such as cameras and mobile phones, with night imaging options.”

The most exciting thing is that the sensors are highly flexible and can be produced cheaply, using the same laser-printers found in homes and offices, and unlike other sensors, do not require specialized manufacturing conditions. I have been working on the colour information captured in clinical photos for charm. I blogged about the decision tree developed by  Seoul National University College of Medicine and Seoul National University Bundang Hospital based on colour data. With this new low-cost sensor capable of differentiating a wide range of wavelengths extending from UV to near infrared, I am sure dermatology imaging is at the threshold of exciting new discoveries.

Dermatology residents having a tough time managing trophic ulcer of Hansens patients, You have a great new sensor coming up! Very soon you will be able to receive an alert on your mobile when the bandage is loose. You will also have another gadget in your coat pocket to measure the bacterial load and PH. Technology and engineering researchers at the University of South Australia have created a range of sensors that can detect changes in a wound environment. You don’t have to rely on their eyes, noses and intuition to predict whether anything is wrong. [2]
An image of two people in mid-infrared ("...
An image of two people in mid-infrared ("thermal") light (false-color) (Photo credit: Wikipedia)

What do you think about the impact of these technologies?

1. "New sensor could light the way forward in low-cost medical ..." 2014. 30 Jun. 2014 <>
2. Smart bandages ready to take wound management to a new level:
Read more »

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Damn Cheap Technology

Cardiff Castle
(Photo credit: beapen)
Couple of years back, when I started doing DermaRoller (needles on a roller, made as expensive as possible by the manufacturer by making the handle gold plated with couple of needles per square inch more than the competitor), I had the notion that this damn cheap technology is going to be more effective than the expensive laser systems. I hoped to find a dermaroller next to the shaving razor as the anti-ageing low-tech equipment. Dr. Murad Alam of Northwestern University in Chicago, who led the study that demonstrated a 41% improvement in acne scars with micro-needling echoed the same feeling: "Needling is so easy to undergo, and potentially so inexpensive, that even a modest benefit may be sufficient to make this a worthwhile treatment for some patients with limited budgets." he said in an interview.[1]

Do you know where your fillers go? (I never did!) If you don’t, read this latest article in Dovepress on the ultrastructural investigation of the lips. Whether you use Juvederm Ultra 3, Juvederm Ultra Smile, Restylane Lipp or Restylane Refresh, you should know where your filler is going, or you may be dangerously close to disaster!  (BTW one of these fillers gives terrible erythema and swelling if injected superficially)This article gives a nice overview of the surgical anatomy of the perioral region too. Carruthers lip fullness grading scale may also be useful.[2]

However the article used ultrasonographic control to “know where the fillers go” which is neither reliable nor practical. I personally feel that impedance measurement may be a better technology to pursue for filler companies to design the next generation needles that cry out when dangerously close to disaster (large blood vessel or a nerve trunk). This 2009 article titled “Impedance-based tissue discrimination for needle guidance” shows that we are/were close.[3]

1.  "Needle rollers shown to improve acne scars | Consultant for ..." 2014. 24 Jun. 2014 <>
2.  "Do you know where your fillers go? An ultrastructural ..." 2014. 24 Jun. 2014 <>
3. Kalvøy, Håvard et al. "Impedance-based tissue discrimination for needle guidance." Physiological measurement 30.2 (2009): 129.

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Artistic Dermatologists

Red lips !! ...item 2.. NSA dreams of quantum ...
(Photo credit: marsmet523)
I am not a social media expert by any stretch of imagination. But two recent articles in Dermatology Times - (Clinical Analysis for today’s skin care specialists), got me excited. The site tacitly admits that social media has almost become clinical.

One article highlights the fact that social media is unreliable as an indicator of your worth as a dermatologist, because disgruntled clients are more likely to comment on social media than satisfied ones. Googling your own name is mooted as a simple way of keeping an eye on your online reputation, my (secret) narcissistic daily pursuit. [Link ]

The second article spells out some candid suggestions for dermatologists to follow to improve their social media presence. Be a friend and a doctor, instead of being an advertisement is a sensible suggestion. I also liked the authors suggestion of promoting the dermatologists' artistic hobbies online to reinforce aesthetic expertise! I am sure I have found many such artistic and not-so-artistic (mis)adventures of my dermatology friends (myself included) on facebook! [Link]

Sorry for not delivering the promised continuation of the dermatology industry series. Will try to do that soon. Did you notice that Step 1 has almost become a rule :) Freaking awesome dermatology clients rock!

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DermGrandRounds - Gamified Dermatology Diagnosis

English: The crowdsourcing process in eight steps.
The crowdsourcing process in eight steps. (Photo credit: Wikipedia)
In our discussion on the #DicoDerm initiative we discussed the challenges of the newly emerging online dermatology diagnosis. We also touched upon the growing importance of crowdsourcing in dermatological diagnosis.  As the facebook kawasaki diagnosis story demonstrates crowdsourcing is here to stay. Patient privacy is the prime concern in the use of social media platforms such as facebook for clinical diagnosis. Dr Howard Green’s DermGrandRounds initiative introduces a secure platform for crowdsourcing that takes it to an exciting new level of gamification! Dermatologists and other associated clinicians participate in a competition to collectively identify difficult dermatology clinical images in a “gamified” process of crowd intelligence. DermGrandRounds also has a dermatology specific wiki. The highest contributors to the crowd sourced diagnosis and the dermatology wiki are rewarded twice weekly. There are no regional barriers to who can participate. DermGrandRounds has a mobile app as well.

On behalf of Dermatologists Sans Borders and on my behalf, congratulations to Dr Green for this initiative. Our work on standardization and metadata enrichment of clinical images (#SkinHelpDesk and #DicoDerm)may also be helpful in extending DermGrandRounds!

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Bell’s methodology and Bell’s law on derma-neologisms?

English: Various coquina shells. Individuals i...
English: Various coquina shells. Individuals in the mollusk species Donax variabilis show diverse coloration and patterning in their phenotypes. (Photo credit: Wikipedia)
Few of my friends posted on Dermatologists Sans Borders about the frustrations of having a unique and rare name. How it is misspelt and how people invent new pronunciations. But there is an upside to this as well. If you discover a “unique” variant of a disease, you can give it your name! Bell’s palsy, disease and sign are already taken :(

Find a unique pattern of vitiligo lesions or LP sparing one side of the wrist and give it your name. You also have the option of naming procedures as well. Hold the scalpel at 47 degrees and call it xyz technique. (Is there a Bell’s procedure? If not, I should register it for future use) Our journals play a major role in encouraging these derma-neologisms. Our dermatology teaching curriculum is also to blame. I am sure the topper in any dermatology postgraduate department will be the student who knows the maximum number of names.

What are the consequences of these seemingly innocuous desire for some to immortalize their names through dermatology literature? (Maybe it is there in other specialities as well). It makes terminology systems too complex. New names may gradually percolate into billing and disease codes making them unnecessarily bloated. New dermatology residents have one more name to learn, one more question to answer during exams, one more tricky question to add for the dermatology quiz master. Gradually regional variations creep into disease descriptions and understanding leading to confusion during conferences and seminars. Infact very few names actually add value to domain knowledge and patient care.

The DermLex(TM) project from Rochester, now transferred to and hosted by AAD is an attempt at reversing this trend. The project aims at organizing the dermatology terms under a formal hierarchy for better domain understanding, not just by humans but by machines too. In my opinion machine readable ontologies need more formal representation as I tried in ONTODerm and then extended in DermBASE (yeap. 2 more names).

What motivated me to write this post though, is not the DermLex, but a little known project with no dermatology representation at present. As vast amounts of Electronic Medical Records data become available for secondary data analysis, we now have the opportunity to identify how diseases are classified as phenotypes in real life as opposed to named disease archetypes with subtle differences, sleeping in the pages of medical textbooks.

Identifying such real world phenotypes will help us in categorizing diseases in a practical way. It will also help clinical research by clearly identifying cases and controls. The home page of the initiative (PheKB) is available here. I also came across a similar methodology in Dr Nigam Shah’s work here.

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About Me

As a Dermatologist and Informatician my research mainly involves application of bioinformatics techniques and tools in dermatological conditions. However my research interests are varied and I have publications in areas ranging from artificial intelligence, sequence analysis, systems biology, ontology development, microarray analysis, immunology, computational biology and clinical dermatology. I am also interested in eHealth, Health Informatics and Health Policy.


Bell Raj Eapen
Hamilton, ON